A Multicenter Randomized Trial of a Checklist for Endotracheal Intubation of Critically Ill Adults

Abstract

Background: Hypoxemia and hypotension are common complications during endotracheal intubation of critically ill adults. Verbal performance of a written, preintubation checklist may prevent these complications. We compared a written, verbally performed, preintubation checklist with usual care regarding lowest arterial oxygen saturation or lowest systolic BP experienced by critically ill adults undergoing endotracheal intubation.

Methods: A multicenter trial in which 262 adults undergoing endotracheal intubation were randomized to a written, verbally performed, preintubation checklist (checklist) or no preintubation checklist (usual care). The coprimary outcomes were lowest arterial oxygen saturation and lowest systolic BP between the time of procedural medication administration and 2 min after endotracheal intubation.

Results: The median lowest arterial oxygen saturation was 92% (interquartile range [IQR], 79-98) in the checklist group vs 93% (IQR, 84-100) with usual care (P = .34). The median lowest systolic BP was 112 mm Hg (IQR, 94-133) in the checklist group vs 108 mm Hg (IQR, 90-132) in the usual care group (P = .61). There was no difference between the checklist and usual care in procedure duration (120 vs 118 s; P = .49), number of laryngoscopy attempts (one vs one attempt; P = .42), or severe life-threatening procedural complications (40.8% vs 32.6%; P = .20).

Conclusions: The verbal performance of a written, preprocedure checklist does not increase the lowest arterial oxygen saturation or lowest systolic BP during endotracheal intubation of critically ill adults compared with usual care.

Trial registry: ClinicalTrials.gov; No.: NCT02497729; URL: www.clinicaltrials.gov.

Keywords: adult; airway management; checklist; critical care; endotracheal; intubation; ventilation.

Figure 1

Patient screening, randomization, and follow-up. CRNA = Certified Registered Nurse Anesthetist.

Figure 2

Rate of performance and verbalization of checklist items by study group. In a 10% convenience sample of enrolled patients, study investigators recorded the performance of each item included on the checklist. Each of the 10 checklist items is listed on the y-axis, and the rate of performance of each item is listed on the x-axis. In the checklist group, the rate of performance and verbalization (right side) of each checklist item was significantly higher than the usual care group. * = three checklist items required verbalization for them to be considered performed; therefore, the rates are the same on the right and left sides; colorimetric CO₂ = colorimetric carbon dioxide detector; MACOCHA = difficult airway assessment scoring system used in the checklist intervention.

Figure 3

Lowest arterial oxygen saturation and systolic BP by study group. The coprimary outcomes of lowest arterial oxygen saturation (left y-axis) and lowest systolic BP (right y-axis) between induction and 2 min after successful endotracheal intubation are displayed for patients randomized to usual care or the preprocedure checklist. Horizontal bars = median and interquartile range.